TO ALL PALLIATIVE CARE PROVIDERS - Hospice …

1 PALLIATIVE care Common Referral Form | Toronto Central PALLIATIVE care Network Please send directly to your desired Hospice PALLIATIVE care provider(s). Do not send to the Toronto Central PALLIATIVE care Network. 1 The PALLIATIVE care Common Referral Form was originated from TIPCU (2004). This Form has been adapted from the Toronto Central PALLIATIVE care Network Common Referral Form. Further uses of this Form are permitted, provided the original is unaltered. Last Modified November 2010 1 Your submission of this form will be taken to explicitly mean that you have gained appropriate permission for release of the information contained to the agencies and services to whom you are submitting this. Please also include your Organization s Release of Information Form, if applicable.

2 TO ALL PALLIATIVE care PROVIDERS (For the purpose of this Form, an individual refers to a patient or client) Please complete this form as thoroughly as possible and PRINT clearly. Each referring agency, group or institution should decide which practitioner(s) is most appropriate to complete each section. Individual s Last Name: First Name: Goals of care / Reason for Referral: Application Checklist (include if available): care protocols attached wound care , central line care , drainage care (pleural/ascitic fluid management) Communication to the individual s family physician of referral for PALLIATIVE care services Copy of completed Do Not Resuscitate Confirmation Form Diagnostic imaging (X-ray, Ultrasound, CT scan, MRI) Recent chest x-ray Infection control management ( MRSA/VRE/C-DIFF, etc.)

3 As available, reports must be current within the last 2 weeks, at time of referral, and include treatment provided. If referring from acute care facility, this information must be included. Recent consultation notes Recent laboratory results Pathology reports Note: Referral Source must be responsible to send referral to all services requested as indicated above; If urgency request is within 1-2 days, a phone contact must be made to the service request Type(s) of services requested Urgency of response Pages Required Community care Access Centre (complete CCAC Medical Referral Form): 1-2 days 1 - 2 weeks Page 1-4 Community PALLIATIVE care Physician (Specify PALLIATIVE Physician Team): Referral is for: Consultative care Primary care 1-2 days 1 - 2 weeks Page 1-3 Hospice Program: Home Visiting Day Program Residential Hospice (specify): 1-2 days 1 - 2 weeks Future 1-2 days 1 - 2 weeks Future Page 1-4 Inpatient PALLIATIVE care Unit (List all units referred): 1-2 days 1 - 2 weeks Future Page 1-4 Other (specify).

4 1-2 days 1 - 2 weeks Future Page 1-4 PALLIATIVE care Common Referral Form | Toronto Central PALLIATIVE care Network Please send directly to your desired Hospice PALLIATIVE care provider(s). Do not send to the Toronto Central PALLIATIVE care Network. Last Modified November 2010 2 Home Address: Apt: Entry Code: Postal Code: Lives Alone Young Children in the Home Smoking in the Home Pet in the Home (specify): Home phone number: Alternate number: Date of birth: (DD/MM/YY) Gender: Faith/Religion: Health card number: Version code: Primary language(s): Translator:(name/phone #): Current location: Home Residential Hospice Other (specify address): Hospital Anticipated hospital discharge date: Primary PALLIATIVE diagnosis.

5 Date of Diagnosis Other relevant diagnosis/symptoms: If cancer diagnosis: metastatic spread: Yes No Describe: If cancer diagnosis: ongoing treatment: Yes No Describe: Individual aware of: Diagnosis: Yes No Prognosis: Yes No Does not wish to know: Yes No Family are aware of: Diagnosis: Yes No Prognosis: Yes No Does not wish to know: Yes No If family is not aware, individual has given consent to inform Family of: Diagnosis Yes No Prognosis Yes No Anticipated prognosis: < 1 month < 3 months < 6 months < 12 months Uncertain Determined by (name and phone number): Functional status: PALLIATIVE Performance Scale (PPS): refer FAQs for more details PPS: 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Resuscitation status: Do Not Resuscitate Yes No Unknown Discussed with: Individual Yes No Family Yes No Family/Informal Caregivers: Provide Power Of Attorney for Personal care if known: Please list all PROVIDERS and Services currently involved: (if Known) Additional list attached Name Phone Fax Family Physician.

6 CCAC Community Nursing Hospice Other Individual s First & Last Name: Name Relationship Home Phone Business/Cell Phone PALLIATIVE care Common Referral Form | Toronto Central PALLIATIVE care Network Please send directly to your desired Hospice PALLIATIVE care provider(s). Do not send to the Toronto Central PALLIATIVE care Network. Last Modified November 2010 3 Co-Morbidities: Check here if documentation is attached Year Diagnosis Year Diagnosis Infection Control: MRSA/VRE (+) C-DIFF (+) Other (specify precaution): Allergies: Yes No Unknown If Yes (please specify): Pharmacy (name and number) If Known: Current medications.

7 Medication list attached (Include complementary alternative medications and over-the-counter medications) Drug Dose Route Interval Drug Dose Route Interval Individual s First & Last Name: Details of social situation, including any needs/concerns of the family: PALLIATIVE care Common Referral Form | Toronto Central PALLIATIVE care Network Please send directly to your desired Hospice PALLIATIVE care provider(s). Do not send to the Toronto Central PALLIATIVE care Network. Last modified November 2010 4 Special care needs: (please check all that apply) Transfusion Hydration: SC or IV Infusion pump(s) Total Parental Nutrition Enteral feeds Dialysis Central line(s) line(s) PortaCath Tracheostomy Oxygen: rate: Thoracentesis Paracentesis Drains/Catheter (specify): Wound care (specify): Therapeutic surface (specify): Other needs: Symptom assessment: ESAS Score at the time of referral: (Adapted from Edmonton Symptom Assessment System ESAS, Capital Health, Edmonton) (rate symptoms.)

8 0 = no symptom, 10 = worst symptom possible See FAQs for details): Pain Tiredness Nausea Depression Drowsiness Appetite Well-being Shortness of breath Other: Date ESAS completed: Insurance Information: Has expressed willingness to pay for private services: Yes No Not Known For inpatient PALLIATIVE care units: Private accommodation requested Any additional information: Individual s First & Last Name: Individual Completing Form: Tel: Fax: (Referring) Physician: Tel: Fax: Date of Referral: (DD/MM/YY)